Treatment-resistant suicidality in a trauma-related disorder initially diagnosed as schizophrenia: a transdiagnostic perspective and response to electroconvulsive therapy

Background: Hallucination-like experiences, affective dysregulation, and social withdrawal are commonly observed in both trauma-related disorders and psychotic conditions. This becomes a complicating factor in the differential diagnosis between these conditions [1,2]. From a transdiagnostic perspective, symptoms of psychosis and PTSD may overlap, yet their underlying mechanisms can differ, requiring distinct treatment approaches. [2, 3]. The variety of symptoms in PTSD makes it difficult to diagnose and treat. Differential diagnosis is important because it directly affects treatment decisions. [3]. Although mechanism of action remains unclear, electroconvulsive therapy(ECT) has been found to be moderately effective at reducing severe symptoms and suicidality in treatment-resistant conditions such as post-traumatic stress disorder (PTSD) [4] In this context, we present a case of PTSD that had been initially diagnosed and treated as schizophrenia for many years, in which persistent suicidal ideation showed marked improvement following ECT.

Methods: Our patient is a 42-year-old female who has been diagnosed with schizophrenia for 20 years. The patient presented with persistent auditory and visual hallucination-like experiences, emotional dysregulation, and chronic suicidal ideation with intent and planning. She had been subjected to sexual abuse for years and her marriage was forced. Her symptoms persisted despite long-term antipsychotic drug treatments including clozapine and amilsulpirid. The patient was reassessed in detail in terms of phenomenology and trauma history.

Results: Upon reassessment, we observed that the hallucinations were not primary psychotic symptoms but were trauma-related intrusions with dissociative features. She experienced trauma-related perceptual experiences such as hearing the voice of a significant attachment figure. These experiences commonly occurred during sleep-wake transitions with preserved insight. There was no evidence of persistent delusions, formal thought disorder, or negative symptoms. In light of these findings, the clinical presentation was considered consistent with PTSD with dissociative features. This formulation was supported by DSM-5 criteria forPTSD, all of which were present in this case, including trauma exposure, re-experiencing symptoms, avoidance behaviors, and functional impairment, with prominent dissociative features. Considering the severity and persistence of suicidality, ECT was administered in a total of 7 sessions, with three sessions delivered in the first week. Clinical improvement became evident after the first week involving resolution of suicidal ideation, normalization of sleep, and disappearance of perceptual disturbances. Suicidal ideation, anhedonia, and amotivation—core features of Depressive disorder—were targeted, and treatment with low-dose Amisulpride at 300 mg was continued while clozapine was discontinued. The continuation of amisulpride represents a limiting factor in determining the attribution of ECT alone

Conclusions: This case highlights that trauma-related dissociative and re-experiencing phenomena may overlap with psychotic symptom domains, potentially complicating diagnostic formulation. A transdiagnostic perspective, emphasizing underlying mechanisms rather than surface-level symptom similarity, may support more accurate clinical interpretation in such presentations.

In this context, electroconvulsive therapy (ECT) may have contributed to improvement in severe symptom domains, particularly suicidality and intrusive re-experiencing, although the contribution of concurrent pharmacological treatment limits causal inference.

Overall, these findings underscore the importance of integrating detailed phenomenological assessment with longitudinal clinical evaluation when approaching complex and diagnostically challenging cases

References

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